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Missouri Application for the State Children’s Health Insurance Program Effective Date: 07/01/2011 Approval Date: Bold Italics Added Information Prior Approval Date: 05/01/2009 Strikethrough Deleted Information - 12 - member per month (PMPM) capitation rate for providing and coordinating health care services for members. Recipients are given an opportunity to select an MCO in his or her area of the State, as well as a PCP within that MCO. Once eligibility is established, recipients receive an enrollment packet which includes a listing of available MCOs, instructions on how to choose an MCO, and who to contact for assistance in determining if their current health care provider is participating in an MCO. Recipients may choose an MCO any time during their open enrollment period by sending in the enrollment form or contacting the Enrollment Broker to enroll over the telephone. For those individuals who do not make an MCO selection, the State uses an algorithm to assign the member to an MCO. Recipients will be covered on a Fee-For-Service basis until enrollment in the MCO is effective. The contracted Enrollment Broker handles the MCO self selection function. All members will be enrolled in an MCO for a period of 12 consecutive months to provide a solid continuum of care. Once a member chooses an MCO or is assigned to an MCO, the member has 90 calendar days from the effective date of coverage to change MCOs for any reason. Children in State care and custody are allowed automatic and unlimited changes in MCO choice as often as circumstances necessitate. The MCOs must assure that members are offered freedom of choice in selecting a PCP. Each MCO shall limit its PCPs to licensed residents specializing in family and general practice, pediatrics, obstetrics and gynecology (OB/GYN), and internal medicine; registered nurses who are advance practice nurses with specialties in family practice, pediatric practice, and OB/GYN practice; and licensed physicians in the following specialties: family and general practitioners, pediatricians, OB/GYN, and internists. 3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42 CFR 457.490(b))